December 2017 Conveyor (LV-025) Incident Report of Investigation
This report complies with sections 25-5-704(b) and 25-5-715(4) of the Colorado Revised Statutes (“C.R.S.”) and the Colorado Passenger Tramway Safety Board Rule 23.3, which require a “report of investigation” following an incident “when “when a death or injury results from a possible malfunction of a 1 passenger tramway.” tramway.” This report provides an overview of the Colorado Passenger Tramway Safety Board and details the incident, the investigation, and the findings of the Board.
Overview of the Colorado Passenger Tramway Safety Board Colorado law established the Colorado Passenger Tramway Safety Board (“Board”) to assist in safeguarding the life, health, property, and welfare of this state through its licensure, inspection and regulation of passenger tramways. Since the establishment of the Board in 1965, there have been seven lift related fatalities as a result of t hree incidents in Colorado.2 To meet its objective of safeguarding the public, the legislature placed the primary responsibility for design, construction, maintenance, operation, and inspection for passenger tramways with area operators, while empowering the Board to prevent unnecessary mechanical hazards in the operation of passenger tramways, and to assure reasonable design and construction, accepted safety devices and sufficient personnel, and that periodic inspections and adjustments are made which are deemed essential to the safe operation of passenger tramways. See §§ 25-5-701 and 705, C.R.S. C.R.S. Toward this end, the Board is authorized to issue licenses, collect fees, receive complaints, conduct investigations, prosecute or enjoin persons violating the Passenger Tramway Safety Act, hold hearings, impose discipline on area operators for such violations, establish technical and safety committees, and promulgate such rules as may be necessary and proper to carry out the provisions of the Passenger Tramway Safety Act, including the use of the standards found in the American National Standard for Passenger Ropeways-Aerial Tramways and Aerial Lifts, Surface Lifts, Tows, and Conveyors-Safety Requirements, Requirements, as promulgated by the American National Standards Institute (“ANSI standards”). See § 25-5-704 25 -5-704 (a), C.R.S. A public passenger tramway shall not be operated in the state of Colorado unless licensed by th e Board. § 25-5-709(2), C.R.S. All lifts in Colorado must must be licensed annually prior to the operating season. See §§ 25-5-711, 712, and 713, C.R.S. Prior to annual licensure, each Colorado lift must be inspected by Board inspection engineers3 to confirm no unreasonable safety hazard exists, and to confirm that the lift is in reasonable compliance with the current ANSI B77.1 Standard, the Passenger Tramway Safety Act and Board Rules. See, § 25-5-712, C.R.S. The Board inspector conducts a visual and and audible inspection of: all safety systems and functions functions of the lift; functionality of all drive systems; brake systems; speed controls; stops and tower safety systems, and any other lift specific systems, including records and other documents. Once the inspection is complete, the Board inspector provides a list of the deficiencies deficiencies
1
This report was prepared in furtherance of the Board’s duty to investigate and report as set forth in §§25-5-704(b) and 25-5715(4), C.R.S. and Board Rule 23.3, and does not, in and of itself, resolve any pending disciplinary complaints before the Board.
2
Colorado Tramway related fatalities occurred in 1976-four fatalities as a result of a cable incident; in 1985- two fatalities as a result of a bullwheel failure; and, a 2016 fatality as a result of a rare dynamic event.
3
Board Inspection Engineers are required to be licensed as professional engineers in the state of Colorado pursuant to §25-5702(5), C.R.S., and Board Rule 22.5.
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observed during the inspection that must be addressed prior to licensure licensure of the lift. See, Board Rule 22.4.4. The area operator operator must certify that these deficiencies have been addressed before the lift lift is licensed for public operation. See, Board Rule 20.2. When the inspector finds deficiencies that may be a risk to public safety, “the inspector shall issue an immediate report to the Board for appropriate investigation and order” pursuant pursuant to section § 25-5-715(5), C.R.S., and Board Rule 22.4.5. In addition to the annual pre-licensure inspection, the Board inspectors conduct unannounced operational inspections during each operating season of the year. See, § 25-5-715, C.R.S., and Board Rule 22.3.2. These inspections focus on operational issues and confirm that deficiencies noted i n the annual inspection have been corrected and that the lift is being maintained and operated in a safe manner. See, Board Rule 1.1. Further, the Board must approve and inspect any major modification to a lift pursuant to § 25-5-710, C.R.S. Prior to major modifications4 of any lift, licensees are required to submit documentation that includes a verification verification statement that the design is in compliance with the applicable rules. The submission must also include a proposed acceptance test procedure to demonstrate the modification meets applicable rules and standards. See, Board Rule 21.3.7. 21.3.7. A Board Inspector Inspector must be present during during the acceptance test. See, Board Rule Rule 21.3.11. Upon successful completion of the test, the area must submit additional documents confirming that the modification was installed according to the original proposal. After all documentation has been reviewed, the Board may issue a license to allow public operation of the lift.
The Incident- Magic Carpet Conveyor (LV-025) at Loveland Ski Area Description of the Incident On the morning of December 28, 2017, lift maintenance worker, Adam Lee, became entangled in a return deflection roller of the return terminal of the LV-025 conveyor at the t he Loveland Ski Area (“Area”). Mr. Lee was in the tunnel beneath the conveyor at the time of the incident. Mr. Lee became entangled with the return deflection roller and did not survive the entanglement. The official cause of death has not been released by the Clear County Medical Examiner. Description of the Lift This “lift” is a 2013 Magic 2013 Magic Carpet conveyor. conveyor. The conveyor belt has a 30-inch wide rubber belt with a slope length of 70 feet and is driven by a 5 HP (horsepower) (horsepower) electric motor. The belt runs on a steel framework that supports the belt for skiers traveling from the bottom terminal to the top terminal and returns, beneath the upper belt, via support rollers rollers spaced at five-foot intervals. The maximum licensed speed of the conveyor belt is 115 fpm (feet per minute); minut e); however, the conveyor normally operates at a speed of 80 fpm for skiers. The tension system is a passive system utilizing two all-thread bolts on each side of a sliding frame that holds the return tension roller. Access to the tension roller roller and tension adjustments can only be made
4
A major tramway modification is defined as: an alteration of the current design of the tramway which results in: a change in the design speed of the system; a change in the rated capacity by changing the number of carriers, spacing of carriers, or load capacity of carriers; a change in the path of the rope; any change in the type of brakes and/or backstop devices or components thereof; a change in the structural arrangements; a change in power or type of prime mover or auxiliary engine; or, a change to control system logic. Board Rule 1.2.4.3. LV-025 Final Investigation Report January 16, 2018 Page 2 of 5
from the lower terminal hatch. The tension roller and tension adjustments can not be accessed from from the tunnel beneath the conveyor. This conveyor is an unusual design 5 in that it is elevated two feet on a frame that has guardrail material on the bottom of the frame to act as skids. The conveyor is stored in a nearby nearby parking lot during the summer. Annual inspection of the lift is conducted in the parking lot, allowing inspectors to visualize all components of the lift, including the tension system and support rollers. When sufficient snowfall occurs, the conveyor is slid into position on the slope for the ski season. The framework underneath the conveyor has a 26 inch high x 48 inch wide wi de crawl space from the top access hatch to the bottom bottom terminal. When boards are placed vertically vertically along the outside of the conveyor this creates a “tunnel” “tunnel” which is cleared of snow beneath the conveyor. This keeps the snow from filling in under the conveyor and affecting normal operations. The snow beneath the bottom terminal prohibits access to the tension unit beyond the bottom deflection roller from the tunnel. As such, there is no exit from the tunnel at the bottom terminal. (See Attachment A).
Investigation The Investigation of this matter commenced on December 28, 2017, the date of the incident, and concluded December 29, 2 2017. 017. The investigation included an on-site inspection and witness interviews. Initial Assessment Immediately following the incident, Area representatives evacuated the LV-025 conveyor and closed the conveyor for public operation. The Area immediately immediately contacted the Clear Creek County Sheriff's Department and then notified the Board Supervisory Tramway Engineer, Lawrence Smith, P.E. (“STE” ), at 12:07 p.m. p.m. The STE responded to the Area, arriving from Denver at 2: OO p.m. Witness Interviews Area personnel were interviewed by the STE on December 28, 2017. 2017. These witness statements provided the STE with the following timeline of events and the functioning of the conveyor prior to, and following the entanglement. The LV-025 conveyor opened and was operating for normal skier traffic beginning at 9:00 a.m. on December 28, 2017. The conveyor operator observed no indication of mechanical mechanical or electrical problems with the conveyor. Between approximately 10:15 a.m and 10:30 a.m., the conveyor conveyor operator witnessed maintenance worker Adam Lee arrive at the top terminal. Mr. Lee smiled and waved to the operator as he opened the hatch cover of the conveyer and accessed the crawl space beneath the conveyor. The conveyor was in operation at this time and continued to operate normally to the skiing public. The conveyor operator had had not called for lift maintenance maintenance to respond to the conveyor.
5
This is one of two such conveyors in Colorado.
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At 11:22 a.m., the conveyor conveyor automatically stopped, indicating an an overspeed fault. Following ski area procedures, the conveyor operator notified Area lift dispatch, who in turn notified lift maintenance to respond to the conveyor. A lift maintenance worker arrived within two to three minutes of the maintenance dispatch. Lift maintenance made two attempts to clear the overspeed fault and restart the conveyor belt. Each restart immediately indicated a speed reference fault and the belt did not move. Suspecting an ice buildup on the drive or return roller that was jamming the roller and prohibiting belt movement, lift maintenance accessed the top terminal crawl space and inspected beneath the conveyor. Inspection of the top drive roller roller revealed no indication of ice buildup or any other issues that may have stopped the conveyor belt. Lift maintenance then walked to the bottom terminal to access the bottom return tension roller. Lift maintenance removed the four bolts of the lower terminal hatch and removed the hatch panel above the tension roller. Upon removing the cover, lift maintenance discovered the entanglement. The lift maintenance worker immediately cut the conveyor belt, pulled the tension roller to the limit of its travel and extracted the entangled work er. Emergency Medical Services were activated. The entang led worker was identified as lift maintenance worker, Adam Lee. Mr. Lee was transported to an area medical center where he was pronounced dead. Review of LV-025 Licensure and Inspections The LV-025 conveyor at Loveland Ski Area has been licensed to operate operate since 2013. During that time, the conveyor was inspected annually for both its licensing and unannounced operational inspections. During its four years of operation, there have been no reported incidents attributed to mechanical or electrical failure. There have been no prior injuries associated with the functioning of this conveyor. The annual licensing inspection for the LV-025 conveyor was completed on September 21, 2017. The Inspection Report dated September 22, 2017, noted a deficiency regarding the need to verify applicable drive safeties with manufacturer and obtain testing procedures for overcurrent and overspeed and a deficiency regarding the need to repair the motor f or the snow chute. In addition , the Area was instructed to complete the applicable items on CPTSB Form 25 -06 prior to opening the conveyor for public use which may or may not have been in place during the inspection. The Area submitted a report to the Board on November 1, 2017, correcting the deficiencies. (See attachment B). Site Investigation At the time of STE arrival, the conveyor was inoperable due to the damage to the belt by lift maintenance in their attempt to rescue the entangled worker. Visual inspection of the conveyor confirmed no damage to the conveyor other t han the belt and no indication of mechanical or electrical failure of the conveyor. No snow or ice buildup was noted beneath the top terminal, along along the length of the conveyor, or at the bottom terminal. Inspection of the tunnel revealed nothing apart from the cut belt that would cause the conveyor to stop operating. The conveyor, the top terminal, the bottom terminal, and the tunnel were photographed. (See Attachment A.)
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Findings At the time of the incident, the conveyor was open to the public under normal skiing operations. Witness interviews confirm the conveyer was operating without any indication of mechanical or electrical issues until the conveyor abruptly stopped at at 11:22 a.m. Inspection of the conveyor found no indication of snow or ice buildup beneat h the top, along the length lengt h of the conveyor or bottom terminal that would cause the unit to stop operating. No mechanical or electrical system failure was observed. In addition, there was no damage to the conveyor beyond the belt, which was cut by lift maintenance in an attempt to rescue the victim. The conveyor abruptly stopped at 11:22 a.m., as a result of the entanglement of the lift maintenance worker with the return deflection roller roller which prohibited belt movement. The prohibited belt movement caused the conveyor to automatically stop and show an overspeed fault. The reason Mr. Lee would enter the tunnel beneath the conveyor remains unclear. Industry standards prohibit the performance of maintenance beneat h a conveyor while the conveyor is in operation.6 In addition, witness interviews and dispatch records confirm there were no mechanical or electrical issues with the conveyor and that Mr. Lee was not dispatched to the conveyor on December 28, 2017.
Conclusion The purpose of the investigation was to comply with sections 25-5-704(b) and 25-5-715(4), C.R.S., and Board Rule 23.3 that require an investigation be conducted “when “ when a death or injury results from a possible malfunction of a passenger tramway . ”
The investigation confirms there was no malfunction of the passenger tramway related to this incident. In fact, the conveyor properly shut down when the return deflection roller jammed at the time of entanglement. The fatality that occurred on December 28, 2017, at Loveland Ski Area was not the result of a possible malfunction of a passenger tramway. Accordingly, the Board’s investigation is concluded.
6
Entanglement in the return system beneath an operating conveyor is a documented hazard, typically resulting in serious injury or loss of limb. Death from entanglement is rare, but not unprecedented.
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ATTACHMENT A
Fig. 1 Top terminal looking downhill.
Attachment A
Fig. 2 Bottom terminal looking uphill.
Attachment A
Fig. 3 Top terminal showing access cover.
Attachment A
Fig. 4 Top terminal showing access cover removed.
Attachment A
Fig. 5 Tunnel beneath the conveyor. View is from next to the top access looking down to the bottom terminal.
Fig. 6 Tunnel beneath the conveyor showing return belt, return belt support rollers and framework.
Attachment A
Fig. 7 Side view of bottom terminal showing belt travel.
Fig. 8 View of the bottom tension unit from the tunnel. The belt is removed from its normal operating position in this photo.
Attachment A
Fig. 9 The normal return belt position is indicated by the cross-hatching and shows the belt running over the top of the smaller deflection roller. Entanglement point is shown by the blue arrow.
Attachment A
Fig. 10 The return terminal hatch cover removed showing the tension return roller. The belt was cut for rescue and not in its normal position. Tension roller (shown with red arrow) is in approximate position of that during operation. Blue arrows indicate location of tension system all-thread.
Attachment A
ATTACHMENT B
